Exhibit XVI Facility Modification Request.pdf

Exhibit XVI (05/24)

ARIZONA DEPARTMENT OF CHILD SAFETY

CONGREGATE CARE

FACILITY MODIFICATION REQUEST

Title License Expiration Date:

Agency E-Mail Address

Date

Applicant Full Legal Name: (Last, First, Middle)

Agency Physical Address City

Agency Phone:

Agency Name

State Zip

Check the type of Contracted Facility Modification you are requesting

If requested information or supporting documentation is not available, a written explanation must be included.

Modification Type (Select All That Apply):

Agency Contact Information:

Decrease Age

Decrease Capacity

Increase Age

Increase CapacityGender Major Remodeling/New ConstructionChange of Agency Name

Change of Facility Name Relocation

Satellite Facility Change of Service Type (GH/SH)

30 Day Temporary Closure

Requested effective date of Change (must be 90 days from the date of the submission of this form)

List Facility Locations Requesting to be Amended

Facility Name Physical Address (Number, Street, City, State, Zip)

Phone Number

Are you requesting the facility to be modified or added?

Modify Add

Additional Requirements

Attached N/A

Proof of Liability Insurance for new location

Facility Staffing Schedule (Only for new facilities)

Agency Roster (Form CS0-1636) detailing paid staff assigned to the proposed facility

Updated policies and procedures

Attach all documents detailed below with your Facility Modification request upon approval Missing documentation shall result in an incomplete notification and may delay your application.

Exhibit XVI (05/24)

ARIZONA DEPARTMENT OF CHILD SAFETY

CONGREGATE CARE

FACILITY MODIFICATION REQUEST

For ADCS Contracts Use Only

Date Request Received Initials Approved Denied

Comments

Acknowledgment And Agreement

I hereby swear and affirm, under penalty of perjury, that the foregoing information is true and correct.

I hereby agree that any false information supplied by me in this application or in support of this application shall be sufficient grounds to deny the application.

I hereby authorize the Arizona Department of Child Safety to investigate me, and agree to cooperate in good faith with the Department in allowing an authorized Department representative to visit this agency or facility at any reasonable time, announced or unannounced, to interview such staff, employees, volunteers or other personnel as may be determined necessary by the Department in conducting its licensing study/investigation.

I agree that the Department may conduct collateral interviews with any source of information regarding this applicant/agency/staff/facility in the course of the licensing study/ investigation. Refusal to allow interviews with any child, employee or staff member shall be grounds to deny this application.

I further understand and agree that the burden and responsibility to supply all required information and documents rest with me, the applicant and failure or refusal to supply such information and/or documents shall be grounds to deny this application.

Title

Applicant Signature

Applicant Name Printed (Last, First, M.I.)

Date Completed:

Please Return This Completed Form To:

Date Request Received Initials

For DCS Use Only

Electronic Mail US Mail Physical Office

Contracts@azdcs.gov Office of Procurement and Contracts

P.O. Box 6030 SC10-20 Phoenix, Arizona 85005-6030

DCS-Contracts Phoenix Corporate Center 3003 N. Central, Suite 108

Phoenix, AZ 85012

Equal Opportunity Employer/Program. The Department of Child Safety (DCS) prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics, or retaliation or any other status protected by federal law, state law, or regulation. Reasonable accommodations to allow a person with a disability to take part in a program, service, or activity are available upon request. To request this document in alternative format or for further information about this policy contact your local office. TTY/TDD Services: 7-1-1. Free language assistance for DCS services is available upon request. Ayuda gratuita con traducciones relacionadas con los servicios del DCS esta disponible a solicitud del cliente.

http://Contracts@azdcs.gov